Citation Nr: 21073337 Decision Date: 12/08/21 Archive Date: 12/08/21 DOCKET NO. 20-25 421 DATE: December 8, 2021 ORDER Service connection for right knee degenerative joint disease is denied. Service connection for left knee degenerative joint disease is denied. Service connection for lumbar spine degenerative joint disease is denied. Service connection for obstructive sleep apnea is denied. An initial 20 percent rating from May 30, 2013 to December 5, 2019 for diabetes mellitus type II is granted. An effective date earlier than May 30, 2013 for the grant of service connection for panic attacks is denied. An effective date earlier than May 30, 2013 for the grant of service connection for coronary artery disease is denied. REMANDED The issue of service connection for gastroesophageal reflux disease is remanded. The issue of service connection for sinusitis is remanded. The issue of service connection for benign prostate hypertrophy is remanded. The issue of an initial rating higher than 50 percent from May 30, 2013 and continuing thereafter for panic attacks is remanded. The issue of an initial rating higher than 10 percent from May 30, 2013 and continuing thereafter for coronary artery disease is remanded. The issue of a total disability rating based on individual unemployability (TDIU) due to service-connected disorders is remanded. FINDINGS OF FACT 1. The Veteran's right knee degenerative joint disease was not incurred in or caused by service. 2. The Veteran did not undergo an in-service event, injury, or disease as to his left knee degenerative joint disease. 3. The Veteran's lumbar spine degenerative joint disease was not incurred in or caused by service. 4. The Veteran did not undergo an in-service event, injury, or disease as to his obstructive sleep apnea. 5. With resolution of the doubt in his favor, from May 30, 2013 to December 5, 2019, the Veteran's diabetes mellitus type II required treatment with an oral hypoglycemic agent and restricted diet. 6. The Veteran did not submit his VA application for compensation within one year of the informal claim dated May 15, 2012 pertaining to panic attacks and/or coronary artery disease. CONCLUSIONS OF LAW 1. The criteria to establish service connection for right knee degenerative joint disease have not been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303(b), (d), 3.307(a)(3), 3.309(a). 2. The criteria to establish service connection for left knee degenerative joint disease have not been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303(b), (d), 3.307(a)(3), 3.309(a). 3. The criteria to establish service connection for lumbar spine degenerative joint disease have not been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303(b), (d), 3.307(a)(3), 3.309(a). 4. The criteria to establish service connection for obstructive sleep apnea have not been met. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(d). 5. The criteria to establish an initial 20 percent rating from May 30, 2013 to December 5, 2019 for diabetes mellitus type II have been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.119, Diagnostic Code (DC) 7913. 6. The criteria to establish an effective prior to May 30, 2013 for the grant of service connection for panic attacks have not been met. 38 U.S.C. § 5101(a); 38 C.F.R. §§ 3.155(b), 3.400. 7. The criteria to establish an effective prior to May 30, 2013 for the grant of service connection for coronary artery disease have not been met. 38 U.S.C. § 5101(a); 38 C.F.R. §§ 3.155(b), 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Navy from June 1966 to February 1970, to include service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2014 rating decision of the Togus, Maine Regional Office (RO). Service Connection Service connection may be granted for a current disability arising from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110. Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of an in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Right and left knee degenerative joint disease Degenerative joint disease, as arthritis, is a "chronic disease" listed under 38 C.F.R. § 3.309(a). Therefore, the provisions of 38 C.F.R. § 3.303(b) are for application. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. For the showing of "chronic" disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such during active service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected unless they are clearly attributable to intercurrent causes. Generally, if a condition noted during active service is not shown to be chronic, then, a "continuity of symptoms" after service is required to establish service connection. 38 C.F.R. § 3.303(b). Additionally, as a chronic disease, degenerative joint disease will be considered to have been incurred in or aggravated by service if the disease becomes manifest to a compensable degree within one year from the date of service separation. 38 C.F.R. § 3.307(a)(3). Continuity of symptomatology may be established by (1) a condition "noted" during service; (2) evidence of post service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and post service symptomatology. Savage v. Gober, 10 Vet. App. 488 (1997). If the condition was one as to which a lay person's observation is competent, medical evidence of "noting" is not necessarily required. Id. The Veteran asserts that his right knee degenerative joint disease (DJD) resulted from trauma after an ammunition pontoon exploded during his service in Vietnam. As to his left knee DJD, the Veteran did not identify an in-service event, injury, or disease but asserts an onset of left knee pain after service separation. The claims will be denied. A December 1967 military personnel record (MPR) titled "Administrative Remarks" reflects that the Veteran served in the Republic of Vietnam. He has the Vietnam Service Medal "by virtue of service onboard the USS Colleton in Southeast Asia in support of military operations in Vietnam from 24 Dec 67 until transferred." An April 1968 service treatment record (STR) reflects the Veteran's report of right shin pain and swelling for approximately four weeks. A right leg physical examination revealed swelling and tenderness. A September 1968 STR reflects the Veteran's report of a right leg lump. The Veteran denied right leg pain and a physical examination revealed old sterile abscess from trauma. In the Veteran's February 1970 separation medical examination report, no lower extremity abnormalities were noted. Notably, STRs do not show complaints or contemporaneous reports pertaining to the Veteran's left knee. The STRs are highly probative evidence because they were generated with the specific view of recording the events they describe. In this respect, they are akin to official records, which generally enjoy a high degree of probative value in the law. Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (observing that although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate if it assists in the articulation of the reasons for the Board's decision). The report of separation from the armed forces (DD Form 214) reflects that the Veteran's duty specialty was disbursing clerk. With resolution of the doubt in his favor as to the in-service event involving his right knee, and therefore his right knee DJD, the event is substantiated. However, the record does not show an in-service event, injury, or disease as to his left knee DJD - to the extent the Veteran claims that his onset of left knee pain after service separation resulted from service, the Veteran has not substantiated having undergone an in-service event, injury, or disease as to his left knee DJD. 38 U.S.C. § 1154(a). Additionally, the Veteran is not competent, as a lay-person, to provide a medical opinion as to the cause of bilateral knee DJD. 38 C.F.R. § 3.159(a)(1). VA and non-VA treatment records do not show complaints or contemporaneous reports pertaining to the Veteran's knees. During the May 2014 VA knee examination, the Veteran reported right knee trauma after an ammunition pontoon explosion during service in Vietnam. The Veteran denied complications from the right knee injury and stated that "it's a bump but I don't have any issues with it." The Veteran did not report an in-service, event, injury, or disease as to his left knee. However, the Veteran reported an onset of bilateral knee pain after separation. Additionally, the Veteran attributed his right knee trouble to his obesity. A bilateral knee radiograph revealed small suprapatellar joint effusion, no evidence of a fracture, and mild medial and patellofemoral compartmental degenerative change evidenced by joint narrowing, subchondral sclerosis, and tiny osteophytes. The Veteran was diagnosed with bilateral knee degenerative joint disease. The VA examiner opined that the Veteran's right knee degenerative joint disease was not incurred in or caused by service because the Veteran did not experience right knee residuals during service and the right knee disorder resulted from the Veteran's obesity. The examiner opined that the Veteran's left knee degenerative joint disease was not caused by any claimed incident of active service and that his left knee disorder resulted from his obesity. The VA medical opinion is highly probative because the examiner had an accurate and complete understanding of the Veteran's medical history and provided a medical conclusion with sufficient rationale. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The VA treatment records, non-VA treatment records, and May 2014 VA examination are highly probative as to the Veteran's lack of bilateral knee pain after service separation because although the Veteran claimed bilateral knee pain after separation, the service medical examiner noted no lower extremity abnormalities at separation, VA and non-VA treatment records do not show complaints or contemporaneous reports pertaining to the Veteran's knees, and the Veteran did not report left knee pain and denied right knee complications during the May 2014 VA examination. Fed. R. Evid. 803(4) (statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy since the declarant has a strong motive to tell the truth in order to receive proper care); Kahana v. Shinseki, 24 Vet. App. 428, 440 (2011); Fountain v. McDonald, 27 Vet. App. 258, 272 (2015) (holding that the Board must first establish a proper foundation for drawing inferences against a claimant from an absence of documentation). As to chronicity and continuity of symptomatology, the Veteran is not credible as to his account of experiencing bilateral knee pain after service separation. In a September 1968 STR, the Veteran reported a right leg lump and denied right leg pain. As noted, a physical examination revealed old sterile abscess from trauma. The service medical examiner noted no lower extremity abnormalities at service separation. VA and non-VA treatment records do not show complaints or contemporaneous reports pertaining to the Veteran's knees. During the May 2014 VA knee examination, the Veteran denied complications from the right knee injury and stated that "it's a bump but I don't have any issues with it." Wilson v. Derwinski, 2 Vet. App. 16 (1991) (emphasizing that symptoms, not treatment, are the essence of any evidence of continuity of symptomatology). A preponderance of the probative evidence is against a finding that the Veteran underwent an in-service event, injury, or disease as to his left knee DJD and that the Veteran's right knee DJD was incurred in or caused by service. As to the Veteran's left knee DJD, STRs do not show complaints or contemporaneous reports pertaining to the Veteran's left knee, the Veteran has not substantiated having undergone an in-service event, injury, or disease as to his left knee DJD based on his duty specialty as disbursing clerk, VA and non-VA treatment records do not show complaints or contemporaneous reports pertaining to the Veteran's left knee, and the Veteran did not report an in-service, event, injury, or disease as to his left knee during the May 2014 VA knee examination. As to the Veteran's right knee DJD, the Veteran denied right leg pain in a September 1968 STR, the service medical examiner noted no lower extremity abnormalities at separation, VA and non-VA treatment records do not show complaints or contemporaneous reports pertaining to the Veteran's right knee, and the Veteran denied right knee complications during the May 2014 VA examination and attributed his right knee disorder to obesity. The May 2014 VA examiner opined that the Veteran's right knee DJD was not caused by service. Significantly, no competent medical provider has opined otherwise. Therefore, service connection is not warranted, and the claims are denied. Lumbar spine degenerative joint disease As noted, degenerative joint disease, as arthritis, is a "chronic disease" listed under 38 C.F.R. § 3.309(a). Therefore, the provisions of 38 C.F.R. § 3.303(b) are for application. Walker, 708 F.3d at 1331. The Veteran asserts that his lumbar spine DJD was caused by service. The claim will be denied. A December 1967 STR reflects the Veteran's report of back pain for approximately four days after falling in bathtub. A physical back examination revealed slight instability and no evidence of a bone or nerve injury from the fall. The service medical examiner did not diagnose the Veteran with a lumbar spine disorder. In the Veteran's February 1970 separation medical examination report, the service medical examiner noted no spine abnormalities. The STRs are highly probative evidence. Rucker, 10 Vet. App. at 73 (1997). A February 2007 non-VA treatment record reflects the Veteran's report of back pain. A January 2011 non-VA treatment record reflects the Veteran's report of back spasms. The Veteran was diagnosed with right paralumbar muscle spasms. A December 2011 non-VA treatment record reflects the Veteran's report of right lower back pain and discomfort. He was diagnosed with right paralumbar muscle spasms. An April 2012 non-VA treatment record reflects the Veteran's report of back pain. During the May 2014 VA thoracolumbar spine examination, the Veteran reported an onset of back pain in the late-1980s. Although the examiner noted a complaint of back pain in the STRs, the Veteran "denied any back conditions while in service." The examiner noted a lumbar spine radiograph dated February 2007 revealed minimal degenerative change and no evidence of herniated nucleus pulposus. The Veteran was diagnosed with lumbar spine DJD. The examiner opined that the Veteran's lumbar spine DJD was not incurred in or caused by service because although the Veteran reported back pain during service, the back pain was a self-limiting condition that resolved. Additionally, the Veteran denied back trouble during service and the examiner attributed the Veteran's lumbar spine DJD due to age. The VA medical opinion is highly probative. Nieves-Rodriguez, 22 Vet. App. at 295. As to chronicity and continuity of symptomatology, although the Veteran reported an instance of back pain during service after falling in a bathtub, the service medical examiner noted no evidence of a bone or nerve injury from the fall, no spine abnormalities were noted at separation, the Veteran reported an onset of back pain in the late 1980s, and the Veteran denied back trouble during service during the May 2014 VA thoracolumbar spine examination. A preponderance of the evidence is against a finding that the Veteran's lumbar spine DJD was incurred in or caused by service. As to chronicity and continuity of symptomatology, there was no combination of manifestations sufficient to identify lumbar spine DJD and the disorder was not noted during service because the service medical examiner noted no evidence of a bone or nerve injury from the in-service fall, no spine abnormalities were noted at separation, the Veteran reported an onset of back pain in the late 1980s, and the Veteran denied in-service back trouble during the May 2014 VA thoracolumbar spine examination. The May 2014 VA examiner opined that the Veteran's lumbar spine DJD was not incurred in or caused by service. Significantly, no competent medical provider has opined otherwise. Therefore, service connection is not warranted, and the claim is denied. Obstructive sleep apnea The Veteran attributes his obstructive sleep apnea to active duty service. The claim will be denied because the Veteran did not undergo an in-service event, injury, or disease as to his obstructive sleep apnea. STRs do not show complaints or contemporaneous reports pertaining to trouble breathing or sleeping. In the Veteran's February 1970 separation medical examination report, the service medical examiner noted no sleeping abnormalities. The STRs are highly probative evidence. Rucker, 10 Vet. App. at 73 (1997). The Veteran has not identified or provided any details as to the nature of an in-service event, injury, or disease concerning his obstructive sleep apnea. Additionally, the Veteran has not substantiated having undergone an in-service event, injury, or disease as to his obstructive sleep apnea due to his duty specialty as a disbursing clerk. 38 U.S.C. § 1154(a). A December 2009 non-VA treatment record reflects the Veteran's diagnosis of sleep disturbance. In a November 2011 non-VA treatment record, the Veteran underwent a follow-up as to a sleep study. The Veteran was diagnosed with obstructive sleep apnea. A May 2012 non-VA treatment record reflects the Veteran's report of trouble breathing and the treating physician noted "sleep apnea?" Under McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006), a VA examination is warranted when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualified, (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, and (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. The issue as to a current disability is substantiated as evidenced by the Veteran's non-VA sleep study reflecting a diagnosis of obstructive sleep apnea. However, obstructive sleep apnea is not a chronic disease listed under § 3.309(a) or a disease associated with exposure to certain herbicide agents under § 3.309(e). The Veteran has not identified or provided any details as to the nature of an in-service event, injury, or disease as to his obstructive sleep apnea. As noted, STRs do not show complaints or contemporaneous reports pertaining to trouble breathing or sleeping and the service medical examiner noted no sleeping abnormalities at separation. Additionally, the Veteran has not asserted and the evidence does reasonably raise that the Veteran's obstructive sleep apnea may be associated with another service-connected disability. Robinson v. Mansfield, 21 Vet. App. 545 (2008) (holding that in reviewing a claim, VA is not required to raise sua sponte all possible theories of entitlement but must consider those bases reasonably raised either by the claimant or the evidence of record). Therefore, a VA examination is not warranted. A preponderance of the evidence is against a finding that the Veteran underwent an in-service event, injury, or disease as to his obstructive sleep apnea. The Veteran has not identified or provided any details as to the nature of an in-service event, injury, or disease concerning his obstructive sleep apnea. The Veteran has not substantiated having undergone an in-service event, injury, or disease as to his obstructive sleep apnea due to his duty specialty. STRs do not show complaints or contemporaneous reports pertaining to trouble breathing or sleeping and the service medical examiner noted no sleeping abnormalities at separation. Therefore, service connection is not warranted, and the claim is denied. Increased Rating Diabetes Mellitus type II Disability evaluations are determined by comparing the Veteran's current symptomatology with the criteria set forth in the Schedule for Rating Disabilities. 38 U.S.C. § 1155. When there is a question as to which of two disability evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. Under DC 7913, a 10 percent rating is assigned for diabetes mellitus type II manageable by restricted diet only. 38 C.F.R. § 4.119, DC 7913. A 20 percent rating is assigned for requiring one or more daily injection of insulin and restricted diet, or; oral hypoglycemic agent and restricted diet. Id. A 40 percent rating is assigned for requiring one or more daily injection of insulin, restricted diet, and regulation of activities. Id. A 60 percent rating is assigned for requiring one or more daily injection of insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. Id. A 100 percent rating is assigned for requiring more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. Id. Note (1) to DC 7913 provides that compensable complications of diabetes are to be rated separately unless they are part of the criteria used to support a 100 percent rating under DC 7913. Id. Noncompensable complications are considered part of the diabetic process under DC 7913. Id. The criteria for rating diabetes mellitus type II are conjunctive, meaning that each element of the criteria is needed to meet the requirements for the specified evaluation. Camacho v. Nicholson, 21 Vet. App. 360 (2007); Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive "and" in a statutory provision means that all the conditions listed in the provision must be met). The Veteran's diabetes mellitus type II (DM) is rated 10 percent disabling from May 30, 2013 to December 5, 2019 and 20 percent disabling from December 6, 2019 and continuing thereafter. The appellate period is from May 30, 2013. In a January 2014 non-VA treatment record, it was noted that the Veteran's "diabetes management started" and the Veteran's treating physician updated the Veteran's medication list to include aspirin once by mouth per day to treat DM. During the May 2015 VA diabetes mellitus examination, the Veteran was diagnosed with DM. The Veteran required management by restricted diet but regulation of activities was not required to treat DM. The Veteran visited his diabetic care provider for episodes of ketoacidosis and hypoglycemia less than two times per month. The Veteran did not have any episodes of ketoacidosis or hypoglycemic reactions requiring hospitalization over the past 12 months. The examiner noted no progressive unintentional weight loss, loss of strength attributable to DM, or any recognized complications of DM. There were no other pertinent physical findings. The examiner indicated that the Veteran "was never started on medications" and managed his DM with a controlled diet. During the December 2019 VA diabetes mellitus examination, the examiner noted treatment from prescribed oral hypoglycemic agents but regulation of activities was not required as part of the Veteran's medical management of DM. The Veteran visited his diabetic care provider for episodes of ketoacidosis and hypoglycemia less than two times per month. The Veteran did not have any episodes of ketoacidosis or hypoglycemic reactions requiring hospitalization over the past 12 months. The examiner noted no progressive unintentional weight loss, loss of strength attributable to DM, or any recognized complications of DM. There were no other pertinent physical findings. The Board will grant a 20 percent initial rating from May 30, 2013 to December 5, 2019 for the Veteran's DM under DC 7913 based on the benefit-of-the-doubt doctrine. The January 2014 non-VA treatment record reflects that the Veteran's treating physician updated the Veteran's medication list to include aspirin once by mouth per day to treat DM. The May 2015 VA examiner noted that the Veteran managed his DM with a restricted diet but regulation of activities was not required to treat the Veteran's DM. Although the VA examiner indicated that the Veteran "was never started on medications" and managed his DM with a controlled diet, the examiner did not consider the January 2014 non-VA treatment record reflecting an updated medication list for the Veteran's DM treatment. The Board will resolve all reasonable doubt in favor of the Veteran. Therefore, a 20 percent initial rating is warranted, and the claim is granted. A preponderance of the evidence is against a finding of an initial or increased rating higher than 20 percent for the entirety of the rating period on appeal for the Veteran's DM under DC 7913. The January 2014 non-VA treatment record did not indicate that the Veteran required a daily injection of insulin or regulation of activities. The May 2015 and December 2019 VA examiner indicated that regulation of activities was not required to treat the Veteran's DM. Therefore, a higher rating is not warranted, and the claim is denied. Effective Date Panic Attacks and Coronary Artery Disease Except as otherwise provided, the effective date of an evaluation and award of pension, compensation, or dependency and indemnity compensation based on an initial claim or supplemental claim will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400. A claimant, his or her duly authorized representative, a Member of Congress, or some person acting as next friend of claimant who is not of full age or capacity may indicate a claimant's desire to file a claim for benefits by submitting an intent to file a claim to VA. An intent to file a claim must provide sufficient identifiable or biographical information to identify the claimant. Upon receipt of the intent to file a claim, VA will furnish the claimant with the appropriate application form prescribed by the Secretary. If VA receives a complete application form prescribed by the Secretary, as defined in paragraph (a) of § 3.160, appropriate to the benefit sought within 1 year of receipt of the intent to file a claim, VA will consider the complete claim filed as of the date the intent to file a claim was received. 38 C.F.R. § 3.155(b). On May 15, 2012, the Veteran submitted and VA received an intent to file claims of service connection, in relevant part, for "coronary artery disease and anxiety." On May 17, 2012, VA notified the Veteran of receiving his informal claim on May 15, 2012 and advised the Veteran to complete and return the enclosed VA Form 21-526, Application For Compensation within one year from the date of the letter. On May 30, 2013, the Veteran submitted and VA received the VA Form 21-526, Application For Compensation pertaining to panic attacks and coronary artery disease. A preponderance of the evidence is against the assignment of effective dates earlier than May 30, 2012 for the grant of service connection for panic attacks and coronary artery disease. On May 15, 2012, the Veteran submitted and VA received an intent to file a claim. On May 17, 2012, VA notified the Veteran of receiving his informal claim on May 15, 2012 and advised the Veteran to complete and return the enclosed VA Form 21-526 within one year from the date of the letter. The Veteran submitted and VA received his VA Form 21-526 on May 30, 2013 more than one year from the May 15, 2012 informal claim and May 17, 2012 VA letter. Therefore, earlier effective dates are not warranted, and the claims are denied. REASONS FOR REMAND The remaining matters are remanded for the following actions: 1. BACKGROUND FOR THE RO ADJUDICATOR The Veteran has a current diagnosis of gastroesophageal reflux disease, sinusitis, and benign prostate hypertrophy. The Veteran has documented in-service stomach and sinus trouble. Additionally, the Veteran asserts that his gastroesophageal reflux disease, sinusitis, and benign prostate hypertrophy were caused by his exposure to Agent Orange in Vietnam. The Veteran has not been afforded VA examinations and the requirements for an examination under McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006) have been met. The Veteran's most recent VA examinations as to his service-connected panic disorder and coronary artery disease was in May 2014. In August 2021, the Veteran's representative submitted a non-VA examination dated January 2017 pertaining to the Veteran's panic disorder. However, an August 2021 statement from the Veteran reflects that his panic disorder and coronary artery disease may have worsened. Therefore, updated VA examinations are warranted. Allday v. Brown, 7 Vet. App. 517, 526 (1995). In an August 2021 statement, the Veteran reported not working a full time job due to his service-connected panic attacks since 1991. Additionally, several VA examinations as to the Veteran's service-connected disorders indicate that the Veteran may be unemployable. The issue of entitlement to a TDIU has been raised. Rice v. Shinseki, 22 Vet. App. 447 (2009). Remand is warranted for due process development for the issue of TDIU, including adjudication by the RO. The Veteran's current employment status is not clear and the Veteran has not submitted a VA Form 21-8940, Application For Increased Compensation. THE REMAND DIRECTIVES FOLLOW. 2. Schedule the Veteran for a VA examination to obtain an opinion as to the nature and etiology of his gastroesophageal reflux disease, sinusitis, and benign prostate hypertrophy. All relevant medical and non-medical records must be made available to the examiner for review of pertinent documents. The examination report should specifically state that such a review was conducted. Gastroesophageal reflux disease: the examiner must provide the following opinions: Was the Veteran's gastroesophageal reflux disease caused by the Veteran's in-service reports of stomach cramps, nausea, and/or diagnosis of gastroenteritis? Was the Veteran's gastroesophageal reflux disease caused by exposure to Agent Orange? THE EXAMINER IS ADVISED THAT THE VETERAN SERVED IN THE REPUBLIC OF VIETNAM AND IS PRESUMED EXPOSED TO AGENT ORANGE. Although the examiner must review the VBMS file, his or her attention is drawn to the following: An April 1968 service treatment record reflects the Veteran's report of stomach cramps. The Veteran was diagnosed with gastroenteritis. A May 1968 service treatment record reflects the Veteran's report of stomach cramps. A physical examination revealed epigastric area abdominal tenderness. The Veteran was diagnosed with gastroenteritis. A June 1969 service treatment record reflects the Veteran's report of nausea. The Veteran treated with Tylenol. In the Veteran's February 1970 service medical examination report, the service medical examiner noted no abnormalities pertaining to gastroesophageal reflux disease. A November 2011 non-VA treatment record reflects the Veteran's diagnosis of gastroesophageal reflux disease. Sinusitis: the examiner must provide the following opinions: Was the Veteran's sinusitis caused by the Veteran's in-service nasal trouble? Was the Veteran's sinusitis caused by exposure to Agent Orange in Vietnam? THE EXAMINER IS ADVISED THAT THE VETERAN IS PRESUMED SOUND AS TO HIS SINUSITIS AND THAT THE VETERAN SERVED IN THE REPUBLIC OF VIETNAM AND IS PRESUMED EXPOSED TO AGENT ORANGE Although the examiner must review the VBMS file, his or her attention is drawn to the following: In the Veteran's February 1966 pre-entrance medical examination report, the service medical examiner noted no sinus abnormalities. In his February 1966 pre-entrance medical history report, the Veteran reported nose trouble and a nose operation at 13 years of age. The examiner noted that the Veteran underwent a resection and that the Veteran's nasal congestion was "NCD" (not currently disabling). A March 1967 service nose radiograph revealed a fracture. A May 1967 service treatment record reflects the Veteran's report of trouble breathing and obstruction from the right side of his nose due to septal surgery one year before service entrance. A physical examination revealed right septum displaced anteriorly and a dorsal flattening deformity. In a May 1967 service treatment record, the Veteran underwent septal rhinoplasty. Pre-discharge diagnosis was deviated nasal septum and discharge diagnosis was external hump deformity. A September 1967 service treatment record reflects the Veteran's report of an infected lesion on the left lateral side of the nose. The service medical examiner noted an infected sinus tract. An October 1967 service treatment record noted the Veteran's rhinoplasty in May 1967 and three weeks post-operation, drainage was noted on the left nasal bridge. The Veteran was treated on several occasions with no resolution. The Veteran underwent a left nasal fistula excision. The service medical examiner noted a well-healed closed wound. He was diagnosed with a left nasal fistula. An October 1969 service treatment record noted the Veteran's 1967 rhinoplasty for a deformity and deviated septum. The Veteran reported minimal airway improvement post-surgery. The service medical examiner noted straight septum, adequate airway, and allergic changes. The Veteran was provisionally diagnosed with a deviated septum. In the Veteran's February 1970 separation medical examination report, the service medical examiner noted no sinus abnormalities. An April 2012 non-VA treatment record noted a history of deviated septum. A January 2013 non-VA treatment record reflects the Veteran's diagnosis of left-sided jaw pain. A physical examination revealed left maxillary sinus tender to palpation. The Veteran was diagnosed with maxillary sinusitis. Benign prostate hypertrophy: the examiner must provide the following opinion: Was the Veteran's benign prostate hypertrophy caused by his exposure to Agent Orange in Vietnam? THE EXAMINER IS ADVISED THAT THE VETERAN SERVED IN THE REPUBLIC OF VIETNAM AND IS PRESUMED EXPOSED TO AGENT ORANGE. Although the examiner must review the VBMS file, his or her attention is drawn to the following: Service treatment records do not show complaints or contemporaneous reports pertaining to the Veteran's prostate. In the Veteran's February 1970 separation medical examination report, no genitourinary abnormalities were noted. Non-VA treatment records dated December 2009 and March 2010 reflect the Veteran's diagnosis of benign prostate hypertrophy. In a June 2010 letter, a non-VA examiner noted the Veteran's report of increased nocturia and decreased urinary stream. A June 2010 non-VA pelvic and bladder ultrasound revealed post-void bladder residuals. In a December 2011 letter, a non-VA examiner noted the Veteran's history of benign prostate hypertrophy. An April 2012 non-VA treatment record reflects the Veteran's diagnosis of benign prostate hypertrophy. A January 2013 non-VA treatment record reflects the Veteran's report of increased nighttime urinary frequency. The Veteran was diagnosed with benign prostate hypertrophy, increased nocturia, and elevated PSA. An October 2013 non-VA treatment record reflects the Veteran's diagnosis of benign prostate hypertrophy. 3. Schedule the Veteran for a VA examination to assist in determining the current severity of his panic disorder and coronary artery disease. 4. Provide the appropriate VCAA notice concerning the claim for a TDIU. 5. Ask the Veteran to complete and return a VA Form 21-8940, Application For Increased Compensation Based On Unemployability, and/or other documents containing the necessary employment and education history. 6. Make reasonable attempts to obtain relevant social security administration records concerning the Veteran's service-connected disorders. 7. If the benefits sought on appeal remain denied, the Veteran should be provided a supplemental statement of the case (SSOC). An appropriate period should be allowed before the case is returned to the Board. Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Cohen, Counsel The Board's action is binding only in this case. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.